Healthcare Provider Details

I. General information

NPI: 1215534805
Provider Name (Legal Business Name): LIMITLESS EVOLUTION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2020
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3524 OSAGE BEACH PKWY
OSAGE BEACH MO
65065-5622
US

IV. Provider business mailing address

3524 OSAGE BEACH PKWY
OSAGE BEACH MO
65065-5622
US

V. Phone/Fax

Practice location:
  • Phone: 573-693-9818
  • Fax:
Mailing address:
  • Phone: 573-693-9818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. JUSTIN DESKIN
Title or Position: OWNER
Credential: FEDERAL GOVERNMENT
Phone: 573-693-9818